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CA - Submission Package - CA2019MS0008O - (CA-19-0050) - Eligibility

CMS-10434 OMB 0938-1188

Package InformationPackage ID CA2019MS0008O

Program Name N/A

SPA ID CA-19-0050

Version Number 4

Submitted By Angeli Sus Lee

Priority Code P2

Submission Type Official

State CA

Region San Francisco, CA

Package Status Review

Submission Date 9/30/2019

Regulatory Clock 9 days remain

Review Status Review 1

Summary Reviewable Units Versions Correspondence Log Compare Doc Change Report Analyst Notes

Review Assessment Report Approval Letter Transaction Logs News Related Actions

of 66Medicaid State Plan Print View

12/20/2019https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0c...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite 5 - 300 (5W) San Francisco, CA 94103-6706

Division of Medicaid and Children's Health OperationsRichard Figueroa Acting Director California Department of Health Care Services 1501 Capitol Avenue Sacramento, CA 95814

Re: Approval of State Plan Amendment CA-19-0050

Dear Richard Figueroa:

On September 30, 2019, the Centers for Medicare and Medicaid Services (CMS) received California State Plan Amendment (SPA) CA-19-0050 to elect authority under section 1902(r)(2) of the Social Security Act (the Act) to apply an income methodology less restrictive than the supplemental security income (SSI) program’s for certain Medicaid applicants and beneficiaries. Specifically, California proposed to disregard income up to 138 percent of the federal poverty level (FPL) for individuals seeking eligibility on the basis of having blindness for the eligibility group described in section 1902(a)(10)(A)(ii)(I) of the Act, and individuals seeking eligibility in the eligibility group described in section 1902(a)(10)(A)(ii)(X) of the Act.

This income disregard is permissible under the authority of section 1902(r)(2) of the Act. .

We approve California State Plan Amendment (SPA) CA-19-0050 with an effective date(s) of August 01, 2020.

Name Date Created

No items available

If you have any questions regarding this amendment, please contact Cheryl Young at [email protected].

Sincerely,

Richard C. Allen

Director, Western Regional Operations Group Center for Medicaid and CHIP Services

Division of Medicaid and Children's Health Operations

Submission - SummaryMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050

Package HeaderPackage ID CA2019MS0008O


Approval Date N/A

Superseded SPA ID N/A

SPA ID CA-19-0050

Initial Submission Date 9/30/2019

Effective Date N/A

State Information

State/Territory Name: California Medicaid Agency Name: California Department of Health Care Services



Submission Component

State Plan Amendment Medicaid

CHIP






Approval Date N/A


SPA ID CA-19-0050


Effective Date N/A

SPA ID and Effective Date

SPA ID CA-19-0050

Reviewable Unit Proposed Effective Date Superseded SPA ID

Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a Disability

8/1/2020 New

Non-MAGI Methodologies 8/1/2020 New

Mandatory Eligibility Groups 8/1/2020 New

Optional Eligibility Groups 8/1/2020 New

Individuals Eligible for but Not Receiving Cash Assistance

8/1/2020 CA-09-009

Age and Disability-Related Poverty Level 8/1/2020 CA-02-002

Page Number of the Superseded Plan Section or Attachment (If Applicable):

CA-09-009, page 6a (Supplement 8a to Attachment 2.6-A) CA-02-002, page 6 (Supplement 8a to Attachment 2.6-A)






Approval Date N/A


SPA ID CA-19-0050


Effective Date N/A

Executive Summary

Summary Description Including Goals and Objectives

This State Plan Amendment is required to implement state Senate Bill (SB) 104 (2019). SB 104 increases the Blind Federal Poverty Level (FPL) and the Aged and Disabled FPL program income limits by increasing the income disregard to all countable income above the SSI/SSP payment standard up to 138% of FPL for the Blind FPL program and 100% up to 138% FPL for the Aged and Disabled FPL program. The income disregard is applied after all other exclusions and disregards. The legislation will expand the existing program by shifting some individuals from Medi-Cal eligibility with a share of cost (SOC) to eligibility without a SOC. For those individuals, the Department of Health Care Services will begin paying their Medicare Part B premiums and managed care capitation. This income disregard is a permissible less restrictive income methodology under 1902(r)(2) authority.

Federal Budget Impact and Statute/Regulation Citation

Federal Budget Impact

Federal Fiscal Year Amount

First 2019 $13586182

Second 2020 $81517092

Federal Statute / Regulation Citation

1396a(a)(10)(A)(ii)(I), (X); 1396a(r)(2)

Supporting documentation of budget impact is uploaded (optional).

Name Date Created

No items available






Approval Date N/A


SPA ID CA-19-0050


Effective Date N/A

Governor's Office Review

No comment

Comments received

No response within 45 days

Other

Describe The Governor does not want to review this SPA.



Submission - Public CommentMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


SPA ID CA-19-0050


Effective Date N/A

Indicate whether public comment was solicited with respect to this submission.

Public notice was not federally required and comment was not solicited

Public notice was not federally required, but comment was solicited

Public notice was federally required and comment was solicited



Submission - Tribal InputMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


SPA ID CA-19-0050


Effective Date N/A

One or more Indian Health Programs or Urban Indian Organizations furnish health care services in this state

Yes

No

This state plan amendment is likely to have a direct effect on Indians, Indian Health Programs or Urban Indian Organizations, as described in the state consultation plan.

Yes

No

Explain why this SPA is not likely to have a direct effect on Indians, Indian Health Programs or Urban

Indian Organizations:

DHCS does not believe a Tribal Notice is required because the proposal does not make changes to the Medi-Cal program that further restrict eligibility; or reduce payment rates or make updates to payment methodologies to Indian health programs; or reduce or restrict access to covered services for American Indian Medi-Cal beneficiaries or increase services reimbursed to Indian health programs. CMS approved DHCS' no-notice request on 8/23/19.



Medicaid State Plan EligibilityIncome/Resource Methodologies

Eligibility Determinations of Individuals Age 65 or Older or Who Have Blindness or a DisabilityMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A

Superseded SPA ID New

User-Entered

SPA ID CA-19-0050


Effective Date 8/1/2020

A. Eligibility Determinations of Individuals Who Are Age 65 or Older or Who Have Blindness or a DisabilityEligibility determinations of individuals who are age 65 or older or who have blindness or a disability are based on one of the following:

1. SSA Eligibility Determination State (1634 State)

The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneficiaries. For all other individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, the state requires a separate Medicaid application and determines financial eligibility based on SSI income and resource methodologies.

2. State Eligibility Determination (SSI Criteria State)

The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility based on SSI income and resource methodologies.

3. State Eligibility Determination (209(b) State)

The state requires all individuals who seek Medicaid eligibility on the basis of being age 65 or older or having blindness or a disability, including SSI beneficiaries, to file a separate Medicaid application, and determines financial eligibility using income and resource methodologies more restrictive than SSI.

B. Additional information (optional)



Medicaid State Plan EligibilityIncome/Resource Methodologies

Non-MAGI MethodologiesMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



The state will apply the methodologies as described below, and consistent with 42 CFR 435.601, 435.602, and 435.831.

A. Basic Financial Methodology

1. The state applies the income and resource methodologies of the SSI program when determining eligibility for a population based on age (65 or older) or having blindness or a disability, with the exceptions described below in B. through G.

2. The state applies the financial methodologies of either the SSI program or the AFDC program in effect as of July 16, 1996 (whichever is most closely related) when determining eligibility for a population based on age (as a child), pregnancy, or status as a caretaker relative, with the exceptions described below in B. through G.

B. Use of Less Restrictive Methodologies

1. The state elects to apply income and/or resources methodologies that are less restrictive than those used under the cash assistance programs, in accordance with 42 CFR 435.601(d).

Yes

No

2. The less restrictive income and resource methodologies are described on the RU for each applicable eligibility group.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



C. Financial Responsibility of Relatives

1. In determining financial eligibility for an individual, the state does not include income and resources from anyone other than the individual's spouse, and for individuals under age 21 or who have blindness or disability, the individual's parent.

a.The state includes the income and resources of a spouse or parent only when they are living with the individual in the same household, except as follows:

i. In the case of spouses who are age 65 or older or who have blindness or disability and who share the same room in a Medicaid institution, the state:

(1) Considers these couples either as living together or as living separately for the purpose of counting income and resources, whichever is more advantageous to the couple.

(2) Considers these couples as living separately for the purpose of counting income and resources.

ii. Where applicable, the state determines income and resource eligibility consistent with the spousal impoverishment rules of section 1924 of the Act, as described in the Resource Assessment and Eligibility reviewable unit.

b. In the case of individuals under age 21 for whom AFDC is the most closely related cash assistance program, the income and resources of parents and spouses are included only if the individual would have been considered a dependent under the state's approved AFDC state plan in effect as of July 16, 1996.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



D. Family Size

1. The family size of an individual for whom the SSI income and resource methodologies are used (as described in section A) includes the persons identified below:

a. The individual applying, or

b. If the individual lives together with his or her spouse, the individual applying and the spouse, or

c. If the individual lives together with his or her parent(s) and the individual is under 21 or has blindness or a disability, the individual applying and the parent(s).

2. The family size of an individual for whom the AFDC income and resource methodologies are used (as described in section A.), includes the persons who would have been included in the family under the state's July 16, 1996 AFDC state plan, except where the state has elected to use the MAGI-like methodologies (as described in section E).

3. The state defines family size for one or more of the following FPL eligibility groups to include others beyond those identified in D.1. and D.2.

Yes

No

a. Qualified Medicare Beneficiaries (described in section 1902(a)(10)(E)(i) of the Act)

b. Specified Low Income Medicare Beneficiaries (described in section 1902(a)(10)(E)(iii) of the Act)

c. Qualifying Individuals (described in section 1902(a)(10)(E)(iv) of the Act)

d. Qualified Disabled and Working Individuals (described in section 1902(a)(10)(E)(ii) of the Act)

e. Age and Disability-Related Poverty Level (described in section 1902(a)(10)(A)(ii)(X) of the Act)

f. Work Incentives (described in section 1902(a)(10)(A)(ii)(XIII) of the Act)

g. Family Opportunity Act Children with a Disability (described in section 1902(a)(10)(A)(ii)(XIX) of the Act)

h. Individuals Receiving State Plan Home and Community-Based Services (described in 42 CFR 435.219)

4. The state uses the same definition of family size for the selected FPL eligibility groups.

Yes

No

5. For the selected FPL eligibility groups, family size is defined as follows:

a. Family is defined as the individual, the individual's spouse and the individual's children under age 18 living together in the same household. If the individual is a child, the child's parents and siblings under age 18 are also included in the household if living together.

b. The state uses another definition of family.

Name of other definition: Description:

Alternative definition of family for QMB, SLMB, and QI 1 Family members include spouse, parents, and children under age 21, if living together, and children 18 years of age or older but under 21, whether living in the home or away from home, being claimed as a dependent by the parent(s) in order to receive a tax credit or deduction for state or federal income tax purposes. However, if the person is 18 to 21 years of age, blind, or disabled, living in the home with the parents, not claimed as a dependent by the parent in order to receive a tax credit or deduction for state or federal income tax purposes, and not currently enrolled in school, college, university, or



Name of other definition: Description:

a course of vocational or technical training to prepare for gainful employment, the person is considered an adult.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



E. Use of MAGI-like Methodologies

1. The state uses MAGI-like methodologies for one or more populations for whom the most closely related cash assistance program would be the AFDC program in effect as of July 16, 1996.

Yes

No






Approval Date N/A


User-Entered

SPA ID CA-19-0050



F. Countable Income Deductions for the Medically Needy

In determining countable income for individuals who are age 65 or older or who have blindness or a disability, the state deducts:

1. Amounts that would be deducted in determining eligibility under SSI.

2. The highest amounts that would be deducted in determining eligibility for optional state supplements if these supplements are paid to all individuals who are receiving SSI or would be eligible for SSI except for their income.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



G. Additional Information (optional)



Medicaid State Plan EligibilityMandatory Eligibility GroupsMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



Mandatory Coverage

A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are:

Families and Adults

Eligibility Group Name

Covered In State Plan

Include RU In Package ?

Included in Another Submission

PackageSource Type ?

Infants and Children under Age 19

CONVERTED

Parents and Other Caretaker Relatives

CONVERTED

Pregnant Women CONVERTED

Deemed Newborns NEW

Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care

NEW

Former Foster Care Children

NEW

Transitional Medical Assistance

NEW

Extended Medicaid due to Spousal Support Collections

NEW

Aged, Blind and Disabled






SSI Beneficiaries NEW

Closed Eligibility Groups

NEW

Individuals Deemed To Be Receiving SSI

NEW

NEW








Working Individuals under 1619(b)

Qualified Medicare Beneficiaries

NEW

Qualified Disabled and Working Individuals

NEW

Specified Low Income Medicare Beneficiaries

NEW

Qualifying Individuals

NEW



Mandatory Eligibility GroupsMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



B. The state elects the Adult Group, described at 42 CFR 435.119.

Yes No

Families and Adults






Adult Group CONVERTED

C. Additional Information (optional)

Eligibility Groups Deselected from Coverage

The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package:

• N/A



Medicaid State Plan EligibilityOptional Eligibility GroupsMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



A. Options for Coverage

The state provides Medicaid to specified optional groups of individuals.

Yes No

The optional eligibility groups covered in the state plan are (elections made in this screen may not be comprehensive during the transition period from the paper-based state plan to MACPro):

Families and Adults






Optional Coverage of Parents and Other Caretaker Relatives

NEW

Reasonable Classifications of Individuals under Age 21

CONVERTED

Children with Non-IV-E Adoption Assistance

CONVERTED

Independent Foster Care Adolescents

CONVERTED

Optional Targeted Low Income Children

CONVERTED

Individuals above 133% FPL under Age 65

NEW

Individuals Needing Treatment for Breast or Cervical Cancer

NEW

Individuals Eligible for Family Planning Services

CONVERTED

Individuals with Tuberculosis

CONVERTED

Individuals Electing COBRA Continuation Coverage

NEW






Include RU In Package


PackageSource Type

Individuals Eligible for but Not Receiving Cash Assistance

NEW

Individuals Eligible for Cash Except for Institutionalization

NEW

Individuals Receiving Home and Community- Based Waiver Services under Institutional Rules

NEW

Optional State Supplement Beneficiaries

NEW

Individuals in Institutions Eligible under a Special Income Level

NEW

PACE Participants NEW

Individuals Receiving Hospice

NEW

Children under Age 19 with a Disability

NEW

Age and Disability-Related Poverty Level

NEW

Work Incentives NEW

Ticket to Work Basic NEW

Ticket to Work Medical Improvements

NEW

Family Opportunity Act Children with a Disability

NEW

Individuals Receiving State Plan Home and Community-Based Services

NEW

Individuals Receiving State Plan Home and Community-Based Services Who Are Otherwise Eligible for HCBS Waivers

NEW



Optional Eligibility GroupsMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



B. Medically Needy Options for Coverage

The state provides Medicaid to specified groups of individuals who are medically needy.

Yes No

The medically needy eligibility groups covered in the state plan are:

1. Mandatory Medically Needy:

Families and Adults





PackageSource Type

Medically Needy Pregnant Women

NEW

Medically Needy Children under Age 18

NEW






PackageSource Type

Protected Medically Needy Individuals Who Were Eligible in 1973

NEW

2. Optional Medically Needy:

Families and Adults





PackageSource Type

Medically Needy Reasonable Classifications of Individuals under Age 21

NEW

Medically Needy Parents and Other Caretaker Relatives

NEW








PackageSource Type

Medically Needy Populations Based on Age, Blindness or Disability

NEW



Optional Eligibility GroupsMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050



Approval Date N/A


User-Entered

SPA ID CA-19-0050



C. Additional Information (optional)

Eligibility Groups Deselected from Coverage

The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package:

• N/A



Medicaid State Plan EligibilityEligibility Groups - Options for Coverage

Individuals Eligible for but Not Receiving Cash AssistanceMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050

Individuals who are eligible for but not receiving federal cash assistance or an optional state supplement.



Approval Date N/A

Superseded SPA ID CA-09-009

User-Entered

SPA ID CA-19-0050



The state covers the optional Individuals Eligible for but Not Receiving Cash Assistance eligibility group in accordance with the following provisions:

A. Characteristics

Individuals qualifying under this eligibility group must meet the following criteria:

1. Meet the eligibility requirements of at least one of the following cash assistance programs:

a. SSI

b. Optional State Supplement

c. AFDC

2. Do not receive cash assistance under these programs.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



B. Individuals Covered

1. The state covers all individuals who meet the characteristics described in section A.

Yes

No

2. The state covers the following populations:

a. Individuals age 65 or older

b. Individuals who have blindness

c. Individuals who have a disability

d. All children under a specified age limit:

e. Reasonable classifications of children

f. Parents and other caretaker relatives

g. Pregnant women

h. Other population






Approval Date N/A


User-Entered

SPA ID CA-19-0050



C. Financial Methodologies

1. In calculating household income and resources for individuals who are seeking eligibility on the basis of being age 65 or older or having blindness or disability, SSI methodologies are used. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

3. Less restrictive methodologies are used in calculating countable income.

Yes

No

The less restrictive income methodologies are:

General income disregard:

Name of disregard: Description:

Blind FPL Expansion

Disregard the amount of countable income over 100% FPL up to 138% FPL. If such disregards are not sufficient to result in an effective income level equal to the SSI/SSP payment level for a disabled individual or, in the case of a couple, the SSI/SSP payment level for a disabled couple, then an income disregard sufficient to achieve that result [shall be applied].

A specified type of income is disregarded:

Name of income type: Description:

In-home caregiver wages As referenced in Supplement 8a of Attachment 2.6-A page 8:

In-home caregiver wages paid to a household member shall be exempt when both of the following conditions are met: 1) The caregiver is being paid for providing the in-home care to his/her spouse or minor child living in the home, and 2) The spouse or minor child is receiving those in-home services through any federal, state or local government program. Payments made by the California Department of Social Services to an in-home care recipient for the purpose of purchasing in-home care



Name of income type: Description:

services, including restaurant meals, shall be exempt. These exemptions shall apply to the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• 1902(a)(10)(A)(ii) • 1902(a)(10)(C)(i)(III) • 1905(p)

Kinship Guardianship Benefit Payments

As referenced in Supplement 8a of Attachment 2.6-A page 9:

As permitted under Section 1902(r)(2), in determining eligibility for the following coverage groups, State funded benefit payments under the State's Kinship Guardianship Assistance Payment Program (also known as Kinship Guardianship Assistance Payment Program -Enhanced) shall be exempt. These coverage groups are:

1902(a)(10)(A)(ii), 1902(a)(10)(C)(i)(III) , and 1905(p).

The following less restrictive methodologies are used:

Name of methodology: Description:

Deductions for family members As referenced in Supplement 1 to Attachment 2.6-A, page 6 and Supplement 8a to Attachment 2.6-A, page 7

An income disregard applicable to the Medically Needy (MN) program (established pursuant to Sections 1902(a)(10)(C), 1902(r)(2), and 1905(a) of the Social Security Act) which is more liberal than those of the most closely related cash assistance program (the former AFDC program for AFDC-MN families and the SSI/SSP cash assistance program for ABD MN individuals) is listed below. Included in this listing is a declaration as to whether the listed more-liberal income disregard replaces an existing AFDC or SSI program disregard.

1. A set of income disregards (see information below), dependent on family size, that, when added to the maximum income standard for the Medically Needy (MN) program permitted under Section 1903(f) of the Social Security Act




(and based on 133 percent of the federally approved Maximum Aid Payment for the former AFDC program in place as of July 16, 1996) produces the effective income standards for the Medically Needy program. This set of income disregards does not replace any income disregard of the SSI program or of the former AFDC program.

First number in the line is the number of family members. Second number in the line is the size of MNL Income disregard. Third number in the line is the MN Income STD. limit. Fourth number in the line is the effective MNL for the MN program:

1, 83, 517, 600 2, 108, 642, 750 2 Adults,134, 800**, 934 3, 134, 800 ,934 4, 150, 950, 1100 5, 184, 1075, 1259 6, 208, 1209, 1417 7, 216, 1334, 1550 8, 242, 1450, 1692 9, 258, 1567, 1825 10, 275, 1684, 1959

For each additional person, add $14.00

**This Maintenance Need Level applies only when at least one of the adults is aged, blind, or disabled.

4. Less restrictive methodologies are used in calculating countable resources.

Yes

No

The less restrictive resource methodologies are:

The state uses a less restrictive methodology with respect to resources set aside for burial.

Specified methodology for the treatment of resources set aside for burial:


Burial Funds As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-a, Page 2:

All of the following shall be disregarded in determining eligibility in their entirety and shall not be applied against a single $1500 limit:




(1) All of the following burial related funds:

(a) The first $1500 paid for clearly designated burial funds such as burial insurance policies with cash surrender values, revocable burial trusts, revocable burial contracts, or other revocable burial arrangements.

(b) Irrevocable burial trusts or irrevocable burial contracts, or other irrevocable burial arrangements.

(c) Burial insurance policies without cash surrender values.

(2) Life insurance policies on the life of any individual in the family shall be exempt if the combined face value of all of the policies on the insured individual is $1500 or less.

(3) All dividends and interest that accrue to and are not removed from the burial fund or policy described in (1) or (2).

The disregard of life insurance policies and burial related funds is allowed for all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

(a)(10)(A)(ii), (a)(10)(C)(i)(III), and 1905(p)

The state uses a less restrictive methodology with respect to the treatment of motor vehicles.

A motor vehicle is disregarded under specific conditions.

Specified conditions:

Description: As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-a Page 11:

One motor vehicle per budget unit shall be exempt regardless of value or use. The above paragraph applies to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):



• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

A specified type of resource is disregarded:

Name of resource type: Description:

Unpaid incurred medical bills

As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 5:

Pursuant to court order in Principe v. Belshe (Sacramento County Superior Court Case No. 96CSOO115), a resource disregard would be allowed equal to the amount of incurred medical bills that are unpaid in the month where there are excess resources for the entire month,

• only when payment of those medical bills occurs in a later month, and • verification of payment is provided.

This disregard would be allowed no earlier than the month of application (may not be one of the three months prior to the month of application).

The requirements listed above would have to be met before eligibility is granted for the month throughout which the excess resources existed.

This disregard would apply only to individuals who have excess resources for the entire month but who are otherwise eligible in that month under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Japanese Reparation Payments As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 6:

Japanese Reparation payments made by the Canadian government shall be exempt from consideration in determining eligibility for Medi-Cal.

Japanese Reparation payments, whether made by




the United States or Canadian governments shall be exempt if received by the spouse or inherited from the spouse who was the original recipient, or both.

Where Japanese Reparation payments, whether made by the United States or Canadian governments, are converted to another form, amounts of otherwise excess, nonexempt resources sufficient to ensure that the amount of the exemption equals the amount of the reparation payments received by the individual or inherited by the spouse of the individual, or both, shall not be considered as resources in determining eligibility for Medi-Cal.

These exemptions shall apply to the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii)(I) • (a)(10)(A)(ii)(VI) •(a)(10)(A)(ii)(VIII) • (a)(10)(A)(ii)(IX) • (a)(10)(A)(ii)(X) • (a)(10)(A)(ii)(XII) • (a)(10)(A)(ii)(XIII) • (a)(10)(A)(ii)(XVII) • (a)(10)(A)(ii)(XVIII) • (a)(10)(A)(ii)(XXI) • (a)(10)(C)(i)(III) • 1905(p)

SSI and AFDC differing methodologies


In considering all of the various items of resources where the SSI program and the AFDC program have differing methodologies, the State shall follow the methodology of the least restrictive of either the SSI program or the AFDC program.

• The general rules contained in the paragraph above shall apply to determine the resource methodologies employed in consideration of all resource items unless a more specific methodology for a specific resource item is otherwise set forth and included in the State plan.

The above paragraphs apply to the resources of all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups




referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Principal residence disregard


The principal residence shall not be considered as a resource if any of the following circumstances exist (this is in addition to the reasons specified by the SSI program and the AFDC program):

• if a child under the age of 21 lives on the property, or • if a dependent relative lives on the property, (for this purpose only, a disabled child age 21 or over shall be considered a dependent relative), • if a sibling or child age 21 or over of the applicant or beneficiary has continuously resided on the property for at least one year immediately prior to the date the applicant or beneficiary entered a skilled nursing facility or intermediate care facility and continues to reside there, or • if the property cannot be readily converted to cash but a bona fide effort is being made to sell the property. A bona fide effort to sell means that the property is listed for sale with a licensed real estate broker for its fair market value established by a qualified real estate appraiser, a good faith effort is being made to sell the property, offers at fair market value are accepted, and the applicant or beneficiary has supplied proof of compliance with these conditions to the county.

The above paragraphs apply to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Bona fide, good faith effort to sell or liquidate resource

As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page




10:

The value of resources shall be disregarded when there is a bona fide, good faith effort being made to sell or liquidate the resource. The value of the resource shall be disregarded for as long as the bona fide good faith effort to sell or liquidate continues to be made. This methodology is essentially the same as the methodology applied to resources being sold or liquidated in the eligibility determinations of the SSI and AFDC program, however, since there is no conditional eligibility in the Medicaid program, the applicant/beneficiary shall not be required to sign, as a condition of eligibility, a statement agreeing to make repayment upon the sale of the property.

The above paragraph applies to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii)) • (a)(10)(C)(i)(III) • 1905(p)

Resources exempted under 1902(a)(10)(A)(ii)(XIII)

As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 14: All resources exempted from consideration as resources for individuals in the optional coverage group under section 1902(a)(10)(A)(ii)(XIII) of the Act on the basis that they are employer or individual retirement arrangements authorized under the Internal Revenue Code shall continue to be exempt from consideration as resources in all other coverage groups subject to the provisions of 1902(r)(2) under which the individual later becomes eligible for medical assistance where the basis for that eligibility is the individual's age, blindness, or disability.





• 1902(a)(10)(A)(ii)(I) • 1902(a)(10)(A)(ii)(X) • 1902(a)(10)(C)(i)

Precertified long-term care insurance policy or health care service plan contract


A resource disregard is given to an individual who has purchased a precertified long-term care insurance policy or health care service plan contract which covers long-term care and has used such policy or plan to pay for services.

Services which the individual receives and are paid for by the precertified long-term care insurance policy or health care service plan contract, which covers long-term care, must not be delivered by a member of the individual's family, unless: • The family member is a regular employee of an organization which is providing the services; and • The organization receives the payment for the services: and • The family member receives no compensation other than the normal compensation for employees in his or her job category.

The amount of the disregard is equal to the lesser of the following amounts: • the amount of payments made for services by the insurance policy; or • the actual charge for the services.

Such disregard is in effect for the lifetime of the individual. The disregard is also allowed if a Medicaid application is filed on behalf of a deceased individual for payment of costs for care and services received by the individual during his or her lifetime.

The disregard of resources is allowed for aged. blind and disabled individuals who are otherwise eligible and: A. Medically Needy [1902(a)(10)(C)(i)(III)], or B. Optional Categorically Needy [1902(a)(10)(A)(ii)]. except those who are included in Section 1902 (a)(10)(A)(ii)(VIII), 1902(a)(10)(A)(ii)(XI) and 1902(a)(10) (A)(ii)(IV) who are receiving Supplemental Security Income




Payments under Title XVI or a State Supplemental Payment. or C. Who are Qualified Medicare Beneficiaries [1905(p)].

Restitution payments made to Holocaust victims

As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 12 and 13:

Excludable restitution payments made to a holocaust victim or his or her heirs or beneficiaries shall be considered an exempt resource for the purpose of determining eligibility to receive Medi-Cal benefits or the amounts of those benefits.

A "holocaust victim" is a person who was persecuted by Nazi Germany, any other Axis regime, or any other Nazi controlled or Nazi-allied country:

(1) on the basis of race, religion, physical or mental disability, or sexual orientation; (2) during any period before, during or after.

An "excludable restitution payment" is any payment or distribution, recovered or returned asset or property, received directly by a holocaust victim or heirs or beneficiaries of a holocaust victim: (1) as compensation pursuant to the German Act Regulating Unresolved Property Claims, as amended (Gesetz zur Regelung offener Vermogensfragen); (2) as a result of a settlement of claims against any entity or individual for any recovered asset. A "recovered asset" is any asset of any type, including any bank deposits, insurance proceeds, artwork, or interest earned on any of these assets, owned by a holocaust victim, withheld from that holocaust victim or his or her heirs or beneficiaries and recovered, returned or otherwise compensated to the holocaust victim or his or her heirs or beneficiaries; (3) as a payment or restitution provided by law, or by a fund, established by any foreign country, the United States of America, or any other foreign or domestic entity, or as a result of a final resolution of a legal action;




(4) as a direct or indirect return of, or compensation or reparation for, assets stolen or hidden from, or otherwise lost to, the individual before, during or immediately after World War II, including any insurance proceeds under policies issued on the individual by European insurance companies immediately before and during World War II; or (5) as interest, payable as part of any payment or distribution described in the paragraph.


• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)






Approval Date N/A


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D. Income Standard Used

The income standard used is the standard of the most closely related cash assistance program.

E. Resource Standard Used

The resource standard used is the standard of the most closely related cash assistance program.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



F. Additional Information (optional)



Medicaid State Plan EligibilityEligibility Groups - Options for Coverage

Age and Disability- Related Poverty LevelMEDICAID | Medicaid State Plan | Eligibility | CA2019MS0008O | CA-19-0050

Individuals who are age 65 or older or who have a disability, with income no higher than 100% FPL.



Approval Date N/A


User-Entered

SPA ID CA-19-0050



The state covers the optional Age and Disability-Related Poverty Level eligibility group in accordance with the following provisions:

A. Characteristics

Individuals qualifying under this eligibility group must meet the following criteria:

1. Meet at least one of the following condition(s):

a. Are age 65 or older; or

b. Have a disability.

2. Have income and resources at or below the standard for this group.






Approval Date N/A


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SPA ID CA-19-0050



B. Individuals Covered

1. The state covers all individuals who meet the characteristics described in section A.

Yes

No






Approval Date N/A


User-Entered

SPA ID CA-19-0050



C. Financial Methodologies

1. SSI methodologies are used in calculating household income and resources. Please refer as necessary to Non-MAGI Methodologies, completed by the state.

2. Less restrictive methodologies are used in calculating countable income.

Yes

No

a. The state uses the same less restrictive income methodologies for all individuals covered.

Yes

No

The less restrictive income methodologies are:

General income disregard:

Name of disregard:

Description:

A and D FPL Expansion

Disregard the amount of countable income over 100% FPL up to 138% FPL. If such disregards are not sufficient to result in an effective income level equal to the SSI/SSP payment level for a disabled individual or, in the case of a couple, the SSI/SSP payment level for a disabled couple, then an income disregard sufficient to achieve that result [shall be applied].

A specified type of income is disregarded:



Name of income type:

Description:

In-home caregiver wages


In-home caregiver wages paid to a household member shall be exempt when both of the following conditions are met: I) The caregiver is being paid for providing the in-home care to his/her spouse or minor child living in the home, and 2) The spouse or minor child is receiving those in-home services through any federal, state or local government program. Payments made by the California Department of Social Services to an in-home care recipient for the purpose of purchasing in-home care services, including restaurant meals, shall be exempt. These exemptions shall apply to the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• 1902(a)(10)(A)(ii) • 1902(a)(10)(C)(i)(III) • 1905(p)

Kinship Guardianship Benefit Payments


As permitted under Section 1902(r)(2), in determining



Name of income type:

Description:

eligibility for the following coverage groups, State funded benefit payments under the State's Kinship Guardianship Assistance Payment Program (also known as Kinship Guardianship Assistance Payment Program -Enhanced) shall be exempt.

These coverage groups are: 1902(a)(10)(A)(ii), 1902(a)(10)(C)(i)(III) , and 1905(p).

The following less restrictive methodologies are used:

Name of methodology:

Description:

Deductions for family members

As referenced in Supplement 1 to Attachment 2.6-A, page 6 and Supplement 8a to Attachment 2.6-A, page 7

An income disregard applicable to the Medically Needy (MN) program (established pursuant to Sections 1902(a)(10)(C), 1902(r)(2), and 1905(a) of the Social Security Act) which is more liberal than those of the most closely related cash assistance program (the former AFDC program for AFDC-MN families and the SSI/SSP cash assistance program for




Description:

ABD-MN individuals) is listed below. Included in this listing is a declaration as to whether the listed more-liberal income disregard replaces an existing AFDC or SSI program disregard.

1. A set of income disregards (see information below), dependent on family size, that, when added to the maximum income standard for the Medically Needy (MN) program permitted under Section 1903(f) of the Social Security Act (and based on 133 percent of the federally approved Maximum Aid Payment for the former AFDC program in place as of July 16, 1996) produces the effective income standards for the Medically Needy program. This set of income disregards does not replace any income disregard of the SSI program or of the former AFDC program.

First number in the line is the number of family members Second number in the line is the size of MNL Income disregard Third number in the line is the MN Income STD.




Description:

limit Fourth number in the line is the effective MNL for the MN program:

1, 83, 517, 600 2, 108, 642, 750 2 Adults,134, 800**, 934 3, 134, 800, 934 4, 150, 950, 1100 5, 184, 1075, 1259 6, 208, 1209, 1417 7, 216, 1334, 1550 8, 242, 1450, 1692 9, 258, 1567, 1825 10, 275, 1684, 1959

For each additional person, add $14.00

**This Maintenance Need Level applies only when at least one of the adults is aged, blind, or disabled.

3. Less restrictive methodologies are used in calculating countable resources.

Yes

No

a. The state uses the same less restrictive resource methodologies for all individuals covered.

Yes

No

The less restrictive resource methodologies are:

The state uses a less restrictive methodology with respect to resources set aside for burial.

Specified methodology for the treatment of resources set aside for burial:


Description:

Burial Funds As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-a, Page 2:




Description:

All of the following shall be disregarded in determining eligibility in their entirety and shall not be applied against a single $1500 limit:

(1) All of the following burial related funds:

(a) The first $1500 paid for clearly designated burial funds such as burial insurance policies with cash surrender values, revocable burial trusts, revocable burial contracts, or other revocable burial arrangements.

(b) Irrevocable burial trusts or irrevocable burial contracts, or other irrevocable burial arrangements.

(c) Burial insurance policies without cash surrender values.

(2) Life insurance policies on the life of any individual in the family shall be exempt if the combined face value of all of the policies on the insured individual is $1500 or less.

(3) All dividends and interest that accrue to and are not removed from the burial fund or policy described in (1) or (2).




Description:

The disregard of life insurance policies and burial related funds is allowed for all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

(a)(10)(A)(ii), (a)(10)(C)(i)(III), and 1905(p)

The state uses a less restrictive methodology with respect to the treatment of motor vehicles.

A motor vehicle is disregarded under specific conditions.

Specified conditions:

Description: As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-a Page 11:

One motor vehicle per budget



unit shall be exempt regardless of value or use. The above paragraph applies to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member



of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

A specified type of resource is disregarded:

Name of resource type:

Description:

Bona fide, good faith effort to sell or liquidate resource


The value of resources shall be disregarded when there is a bona fide, good faith effort being made to sell or liquidate the




Description:

resource. The value of the resource shall be disregarded for as long as the bona fide good faith effort to sell or liquidate continues to be made. This methodology is essentially the same as the methodology applied to resources being sold or liquidated in the eligibility determinations of the SSI and AFDC program, however, since there is no conditional eligibility in the Medicaid program, the applicant/beneficiary shall not be required to sign, as a condition of eligibility, a statement agreeing to make repayment upon the sale of the property. The above paragraph applies to all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Restitution payments made to Holocaust victims

As referenced in SUPPLEMENT 8b TO ATTACHMENT 2.6-A Page 12 and 13:

Excludable restitution




Description:

payments made to a holocaust victim or his or her heirs or beneficiaries shall be considered an exempt resource for the purpose of determining eligibility to receive Medi-Cal benefits or the amounts of those benefits.

A "holocaust victim" is a person who was persecuted by Nazi Germany, any other Axis regime, or any other Nazi-controlled or Nazi-allied country: (1) on the basis of race, religion, physical or mental disability, or sexual orientation; (2) during any period before, during or after.

An "excludable restitution payment" is any payment or distribution, recovered or returned asset or property, received directly by a holocaust victim or heirs or beneficiaries of a holocaust victim: (1) as compensation pursuant to the German Act Regulating Unresolved Property Claims, as amended (Gesetz zur Regelung offener Vermogensfragen); (2) as a result of a settlement of claims against any entity or individual for any recovered asset. A "recovered




Description:

asset" is any asset of any type, including any bank deposits, insurance proceeds, artwork, or interest earned on any of these assets, owned by a holocaust victim, withheld from that holocaust victim or his or her heirs or beneficiaries and recovered, returned or otherwise compensated to the holocaust victim or his or her heirs or beneficiaries; (3) as a payment or restitution provided by law, or by a fund, established by any foreign country, the United States of America, or any other foreign or domestic entity, or as a result of a final resolution of a legal action; (4) as a direct or indirect return of, or compensation or reparation for, assets stolen or hidden from, or otherwise lost to, the individual before, during or immediately after World War II, including any insurance proceeds under policies issued on the individual by European insurance companies immediately before and during World War II; or (5) as interest, payable as part of any payment or distribution described in the




Description:

paragraph.


• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Resources exempted under 1902(a)10(A)(ii)(XIII)


All resources exempted from consideration as resources for individuals in the optional coverage group under section 1902(a)(10)(A)(ii)(XIII) of the Act on the basis that they are employer or individual retirement arrangements authorized under the Internal Revenue Code shall continue to be exempt from consideration as resources in all other coverage groups subject to the provisions of 1902(r)(2) under which the individual later becomes eligible for medical assistance where the basis for that eligibility is the individual's age, blindness, or disability. These exemptions shall apply to the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):




Description:

• 1902(a)(10)(A)(ii)(I) • 1902(a)(10)(A)(ii)(X) • 1902(a)(10)(C)(i)

Precertified long-term care insurance policy or health care service plan contract


A resource disregard is given to an individual who has purchased a precertified long-term care insurance policy or health care service plan contract which covers long-term care and has used such policy or plan to pay for services.

Services which the individual receives and are paid for by the precertified long-term care insurance policy or health care service plan contract, which covers long-term care, must not be delivered by a member of the individual's family, unless:

• The family member is a regular employee of an organization which is providing the services; and • The organization receives the payment for the services: and • The family member receives no compensation other than the normal compensation for employees in his or her job category.




Description:

The amount of the disregard is equal to the lesser of the following amounts: • the amount of payments made for services by the insurance policy; or • the actual charge for the services.

Such disregard is in effect for the lifetime of the individual. The disregard is also allowed if a Medicaid application is filed on behalf of a deceased individual for payment of costs for care and services received by the individual during his or her lifetime.

The disregard of resources is allowed for aged. blind and disabled individuals who are otherwise eligible and: A. Medically Needy [1902(a)(10)(C)(i)(III)], or B. Optional Categorically Needy [1902(a)(10)(A)(ii)]. except those who are included in Section 1902 (a)(10)(A)(ii)(VIII), 1902(a)(10)(A)(ii)(XI) and 1902(a)(10)(A)(ii)(IV) who are receiving Supplemental Security Income Payments under Title XVI or a State Supplemental Payment. or C. Who are Qualified Medicare Beneficiaries [1905(p)].




Description:

Unpaid incurred medical bills


Pursuant to court order in Principe v. Belshe (Sacramento County Superior Court Case No. 96CSOO115), a resource disregard would be allowed equal to the amount of incurred medical bills that are unpaid in the month where there are excess resources for the entire month, • only when payment of those medical bills occurs in a later month, and • verification of payment is provided.

This disregard would be allowed no earlier than the month of application (may not be one of the three months prior to the month of application).

The requirements listed above would have to be met before eligibility is granted for the month throughout which the excess resources existed.

This disregard would apply only to individuals who have excess resources for the entire month but who are otherwise eligible in that month under




Description:

California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii)• (a)(10)(C)(i)(III) • 1905(p)

Japanese Reparation Payments


Japanese Reparation payments made by the Canadian government shall be exempt from consideration in determining eligibility for Medi-Cal.

Japanese Reparation payments, whether made by the United States or Canadian governments shall be exempt if received by the spouse or inherited from the spouse who was the original recipient, or both.

Where Japanese Reparation payments, whether made by the United States or Canadian governments, are converted to another form, amounts of otherwise excess, nonexempt resources sufficient to ensure that the amount of the exemption




Description:

equals the amount of the reparation payments received by the individual or inherited by the spouse of the individual, or both, shall not be considered as resources in determining eligibility for Medi-Cal.


• (a)(10)(A)(ii)(I) • (a)(10)(A)(ii)(VI) • (a)(10)(A)(ii)(Vlll) • (a)(10)(A)(ii)(IX) • (a)(10)(A)(ii)(X) • (a)(10)(A)(ii)(Xll) • (a)(10)(A)(ii)(Xlll) • (a)(10)(A)(ii)(XVll) • (a)(10)(A)(ii)(XVlll) • (a)(10)(A)(ii)(XXI) • (a)(10)(C)(i)(lll) • 1905(p)

SSI and AFDC differing methodologies


In considering all of the various items of resources where the SSI program and the AFDC program have differing methodologies, the State shall follow the methodology of the least restrictive of either the SSI program or the AFDC program.

• The general rules contained in the paragraph above shall apply to




Description:

determine the resource methodologies employed in consideration of all resource items unless a more specific methodology for a specific resource item is otherwise set forth and included in the State plan.

The above paragraphs apply to the resources of all applicants and recipients who are otherwise eligible under California's State Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)

Principal residence disregard


The principal residence shall not be considered as a resource if any of the following circumstances exist (this is in addition to the reasons specified by the SSI program and the AFDC program):

• if a child under the age of 21 lives on the property, or

• if a dependent relative lives on the property, (for this purpose




Description:

only, a disabled child age 21 or over shall be considered a dependent relative),

• if a sibling or child age 21 or over of the applicant or beneficiary has continuously resided on the property for at least one year immediately prior to the date the applicant or beneficiary entered a skilled nursing facility or intermediate care facility and continues to reside there, or

• if the property cannot be readily converted to cash but a bona fide effort is being made to sell the property. A bona fide effort to sell means that the property is listed for sale with a licensed real estate broker for its fair market value established by a qualified real estate appraiser, a good faith effort is being made to sell the property, offers at fair market value are accepted, and the applicant or beneficiary has supplied proof of compliance with these conditions to the county.

The above paragraphs apply to all applicants and recipients who are otherwise eligible under California's State




Description:

Plan and who are also a member of one of the following coverage groups referenced in the Social Security Act at Section 1902(r)(2):

• (a)(10)(A)(ii) • (a)(10)(C)(i)(III) • 1905(p)






Approval Date N/A


User-Entered

SPA ID CA-19-0050



D. Income Standard Used

The income standard for this eligibility group is:

1. 100% FPL

2. A lower percent of the FPL:






Approval Date N/A


User-Entered

SPA ID CA-19-0050



E. Resource Standard Used

The resource standard used is:

1. The resource limit for the SSI program; or

2. The resource limit used in the state's medically needy program, if higher.






Approval Date N/A


User-Entered

SPA ID CA-19-0050



F. Additional Information (optional)



PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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